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Submission to the Royal Commission Into Aged Care Quality and Safety: Aged Care Program Redesign

Submission by the

Australian Physiotherapy Association

January 2020

Authorised by: Phil Calvert National President Australian Physiotherapy Association Level 1, 1175 Toorak Rd Camberwell VIC 3124 Phone: (03) 9092 0888 Fax: (03) 9092 0899

www.australian.physio

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Contents

Submission to the Royal Commission ............................................................................................................... 1

Into Aged Care Quality and Safety: Aged Care Program Redesign .................................................................. 1

Introduction ...................................................................................................................................................... 7

The scope of physiotherapy for older Australians ....................................................................................... 7

Recommendation 1 ....................................................................................................................................... 8

Proposed principles ........................................................................................................................................... 8

Recommendation 2 ....................................................................................................................................... 9

Recommendation 3 ....................................................................................................................................... 9

Access, information, assessment and system navigation ................................................................................. 9

Consumer education campaigns ................................................................................................................. 10

Peer educator program ............................................................................................................................... 10

Allied health workforce education program ................................................................................................. 11

Digital literacy .............................................................................................................................................. 11

Face to face................................................................................................................................................. 11

Recommendation 4 ..................................................................................................................................... 12

Recommendation 5 ..................................................................................................................................... 12

Recommendation 6 ..................................................................................................................................... 12

Recommendation 7 ..................................................................................................................................... 12

Recommendation 8 ..................................................................................................................................... 12

Recommendation 9 ..................................................................................................................................... 12

Investment stream ........................................................................................................................................... 12

Crisis interventions ...................................................................................................................................... 13

Recommendation 10 ................................................................................................................................... 14

Funding for new interventions ..................................................................................................................... 14

Recommendation 11 ................................................................................................................................... 15

Care stream ..................................................................................................................................................... 15

Specialist and in reach services ...................................................................................................................... 16

Telehealth.................................................................................................................................................... 17

Recommendation 12 ................................................................................................................................... 17

Designing for diversity ..................................................................................................................................... 17

Co-design .................................................................................................................................................... 17

Recommendation 13 ................................................................................................................................... 18

Quality regulation ............................................................................................................................................. 18

Skilled workers ............................................................................................................................................ 19

Recommendation 14 ................................................................................................................................... 20

Recommendation 15 ................................................................................................................................... 20

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Conclusion ..................................................................................................................................................... 20

Australian Physiotherapy Association ........................................................................................................ 21

References ............................................................................................................................. 22

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Executive Summary The Australian Physiotherapy Association (APA) welcomes this opportunity to make a

submission to the Royal Commission into Aged Care Quality and Safety, Aged Care Program

Design, on behalf of the physiotherapy profession.

We support all efforts to reshape the currently flawed system and remove barriers that

prevent older Australians from understanding and accessing the information and services

available to them.

Most importantly, this is an unprecedented opportunity to create a program that places the

human rights of older Australians at its core by funding early interventions and ongoing safe

and high quality care.

For any redesign of the Aged Care Program to succeed, it must ensure:

• older people and their representatives have choice and control about what care they receive and where they receive it

• safe and high quality care is timely, accessible and equitable

• independence in older people is maximised as long as possible

• a smooth transition between health and aged care

• accessibility is maximised by creating an affordable, equitable system.

The foundations of the program must include:

• consistency in approach between funders (eg. adopt the National Disability Insurance

Scheme’s consumer choice approach) to reduce consumer and provider burden

• early comprehensive assessment

• tailored, individualised support

• setting agnostic funding

• telehealth regardless of setting where there is evidence to support equivalent efficacy and safety.

While we are broadly supportive of the Aged Care Program Redesign, we want to ensure that screenings of older Australians entering the system and the role of Care Finders is undertaken by allied health professionals.

This would ensure consistent, correct and timely support and advice – which we know is crucial as even incremental changes in an older person’s condition can have serious consequences.

In providing feedback on the Aged Care Program Redesign Consultation Paper, we have responded to questions within our scope of expertise and omitted those that are not relevant to our profession.

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Summary of Recommendations

Recommendation 1

We recommend the Royal Commission re-orient aged care services to evidence-based early

interventions, including physiotherapy, to improve the quality and safety of care provided.

Recommendation 2

We recommend the first proposed principle be expanded to read: To address this failure, we propose that the design of the aged care system should be underpinned by respect and support for the human rights, choices, identity and dignity of older people.

Recommendation 3

We recommend the second principle be expanded to read: To address this failure, we propose that the design of the aged care system should ensure safe and high quality care and services are fundamental to the operation, funding and regulation of the system.

Recommendation 4

Establish a peer educator program that engages retirees to help older Australians navigate

the aged care system.

Recommendation 5

Engage specialist support workers to visit people in their homes and communities in rural and remote areas and help them to navigate the aged care system.

Recommendation 6

Position the allied health workforce as key sources of information for navigating the aged care system to facilitate access.

Recommendation 7

Develop a comprehensive consumer-facing campaign to educate the broader community about new changes to the aged system, including education about the value allied health providers can make to an older person

Recommendation 8

Implement face-to-face learning initiatives to improve digital literacy and confidence among older Australians.

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Recommendation 9

Ensure face-to-face assessments and services are available to all older people to help them access appropriate assessment, services and care.

Recommendation 10

Enable early comprehensive assessment and care delivered by a multidisciplinary team to

optimise wellness, health and quality of life.

Recommendation 11

Fund a 12-week, restorative and reablement program of physiotherapy at admission into a

residential aged care facility and after a significant trigger event such as a hip fracture.

Recommendation 12

Fund provision of physiotherapy services via telehealth to ensure all older Australians have timely access to safe and high quality care.

Recommendation 13

Collaborate with older people from all cultures and background to co-design and evaluate the effectiveness of the aged care system.

Recommendation 14

Avoid additional regulation of already highly regulated registered allied health professions, including physiotherapy.

Recommendation 15

Preferential appointment of allied health workforce to conduct early screenings and in the role of Care Finders to ensure older Australians receive correct and expert advice at each stage of their aged care journey.

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Introduction

The Australian Physiotherapy Association (APA) welcomes this opportunity to make a

submission to the Royal Commission into Aged Care Quality and Safety, Aged Care Program

Redesign, on behalf of the physiotherapy profession.

In Australia, the scope of practice of the physiotherapy profession is diverse and innovative.

We recognise that a major challenge facing modern health systems internationally is how to

ensure that quality services are available to all citizens, including the elderly who are living

in the community and residential aged care facilities. We also recognise that with an ageing

population in Australia, demand for services will increase. People need the most appropriate,

high quality and safe care, as they age.

Consumer needs will only be met in an aged care environment that rewards safe, high

quality, preventive, reablement, and restorative care, including physiotherapy.

Our view is that the current Aged Care Funding Instrument incentivises illness. While we

support the proposed new Australian National Aged Care Classification (AN-ACC) model, it

does not provide direct funding for the restorative and reablement care physiotherapy

provides in residential care. This is a significant shortfall that must be addressed.

Continuity of care in the move from home care to residential care must also be a priority to

ensure older Australians are living their best lives as long as possible. Currently and in the

future under the proposed AN-ACC model, older Australians receiving physiotherapy care at

home will lose that entitlement when moving into a residential facility.

The aged care system should be re-oriented to ensure access to physiotherapy is available

regardless of setting and continuity of care for older Australians.

The scope of physiotherapy for older Australians

The physiotherapy profession is a fundamental provider of high quality, safe services for

ageing Australians and it is important they are able to access it when and how they need it.

Physiotherapists play a substantial role working with and supporting the older person in

maximising their health, wellbeing and quality of life as they age.

A broad range of physiotherapist-led interventions is effective and cost-effective in improving

physical ability and function for patients within the RACF setting (Bradshaw, Playford & Riazi,

2012) (Brett, Noblet, Jorgensen & Georgiou, 2019).

Physiotherapy is effective and provides economic value in areas including:

• maintaining and improving mobility

• pain management

• falls prevention and reduction and minimising harm from falls

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• independence in activities of daily living

• maintaining and improving continence

• behavioural and psychological symptoms of dementia

• improved functioning

• optimising comfort.

The profession’s broad scope also includes the management of fatigue, shortness of breath,

exercise tolerance, oedema, deconditioning, frailty, contractures, sleep and rest, skin

integrity, and more in the RACF and community care setting.

A core element of this scope is assessment of a person’s capacity to move, and keep moving.

The achievement of this is frequently multifactorial and can include implementing

programmes into daily life to maximise function, and specific therapy prescription, including

exercise and assistive technology, varying from basic aids to more complex and customised

equipment. Physiotherapists build on an individual’s strengths and address impairments

relating to activity and participation within the RACF and other relevant environments. The

interventions and support services provided by physiotherapists, along with regular

communication with older people and their families, provide an opportunity to deliver

consumer driven care that focuses on quality of life care.

It is important older people have access to physiotherapy care when and how they need it.

Physiotherapists work alongside and with the older person, their advocates and the

workforce, to maximise independence, quality of life and dignity. The seemingly smallest and

incremental change implemented by a physiotherapist can positively affect the older person’s

physical, mental, emotional and social wellbeing.

Recommendation 1

We recommend the Royal Commission re-orient aged care services to evidence-based early

interventions, including physiotherapy, to improve the quality and safety of care provided.

Proposed principles

The APA supports the proposed Aged Care Program Redesign principles with suggested additions. We believe a human rights approach should be applied to the design, implementation and evaluation of the aged care program and be reflected in the principles.

It should also reflect The Charter of Aged Care Rights, specifically its first point: “I have the right to safe and high quality care and services, have my identity, culture and diversity valued and supported.”

The APA emphasises the importance of the redesigned program being achievable and aspirational. We need a system that has viable application for the sector.

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The APA believes reform must ensure:

• older people and their representatives have choice about what care they receive and where they receive it

• safe and quality care is accessible and equitable

• maximise independence in older people as long as possible

• smooth transition of care and clear communication between health and aged care

• affordability.

Recommendation 2

Expand the first proposed principle to read: To address this failure, we propose that the design of the aged care system should be underpinned by respect and support for the human rights, choices, identity and dignity of older people

Recommendation 3

Expand the second principle to read: To address this failure, we propose that the design of the aged care system should ensure safe and high quality care and services are fundamental to the operation, funding and regulation of the system

Access, information, assessment and system navigation

We believe all Australians, regardless of location, demographics or socio-economic status,

should be able to access high quality and safe care as they age, in the environment of their

choosing.

We are concerned that many older Australians, particularly those people from diverse

backgrounds, are not receiving adequate access to aged care services. This includes

Aboriginal and Torres Strait Islander peoples, Culturally And Linguistically Diverse (CALD)

individuals, and those who identify as lesbian, gay, bisexual, transsexual or intersex (LGBTI),

or other groups.

The aged care program must be accessible to all older Australians. Consumers need clear, inclusive and consistent information delivered in multiple formats and languages. They also need to be able to choose how, where and when they access this information.

Older people must not be discriminated against because of their preferences. Equitable access is vital.

The My Aged Care website is currently the key source of information about the aged care system. Other information points for older people should include:

• a dedicated and well-resourced phone line

• creating dedicated information desks at centres that older people already attend such as Centrelink offices, community/neighbourhood hubs and local councils/shires

• literature distributed at the aforementioned centres, local libraries and GP/allied health practices

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• dedicated social media pages as older Australians have the fastest rates of social media take up than any other aged group.

We are aware the government is engaged in an aged care navigator trial, testing different

types of services and activities to help people learn more about programs and how to access

them. We applaud this initiative.

The APA believes the following approaches will build greater understanding and effective use of the aged care system.

Consumer education campaigns

Community education campaigns and awareness activities – social marketing - are vital to ensuring older people know how to access information and enter the aged care system.

We know from research that there is evidence that interventions adopting social marketing principles can be effective in changing consumer behaviour with a range of target groups, and in different settings (Stead, Gordon, & Angus, 2007).

(Social marketing is the use of marketing concepts in programmes designed to influence the voluntary behaviour of target audiences in order to improve health and society.)

The main source of information for older Australians is currently the My Aged Care website and physiotherapists report that many of their older clients do not know it exists or are unsure about how to find relevant content.

Widespread promotion of the My Aged Care website and all other information sources and entry points must be urgently undertaken. There is an opportunity to disseminate information via dedicated sessions at local council/shire offices, local libraries, community neighbourhood houses and at Centrelink offices.

Social marketing cannot be effective in isolation – they need to reinforce the messages with high visibility, building communities of support, calls to action and feedback loops.

Peer educator program

Education must be reinforced consistently and by educators with expert knowledge, including those in a volunteer capacity.

We recommend the establishment of a peer educator program that engages retirees to help their peers navigate the aged care system.

Within the physiotherapy profession, research has demonstrated that peer educators have the potential to effectively deliver falls prevention education to older adults, and influence acceptance of the message, as they possess the peer-to-peer connection that facilitates optimal engagement (Khong, Farringdon, & Hill, 2015).

It’s clear that older Australians respond well to educators who understand their experiences and challenges.

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A buddy system of volunteers can also be leveraged to help older people use technology, navigate the aged care system – including the interface with health and other services – and access services.

We recommend engaging specialist support workers – that could be peer educators - to visit people in their homes and communities in rural and remote areas. Older Australians in these communities may otherwise be discouraged from accessing information and support due to the burden of travel.

Allied health workforce education program

It is important the allied health and general practice workforce, including physiotherapists, are well equipped with up-to-date knowledge about how to navigate the aged care system.

The primary health workforce are major providers of day-to-day services and have strong, long standing relationships with the community. They function as trusted providers of information and can leverage access into a complex aged care system.

There are more than 33,000 physiotherapists alone who could be educated and enlisted to support older Australians in their journey from the system’s entry point.

Digital literacy

Face-to-face education initiatives to improve digital literacy and confidence among older Australians must also be implemented urgently.

These will allow greater access for those seeking information online but also enable greater involvement by older people in co-designing future services.

Research has shown that there is a strong relationship between age and digital literacy levels: three-quarters of the digitally disengaged group over 50 were aged 70 years and over (Office of the eSafetyCommissioner, 2018).

From the research, we know that many older Australians are interested in developing and acquiring new digital skills but are intimidated, embarrassed to seek help and/or have concerns about online safety. These factors pose a real barrier to building digital confidence.

Seventy-two per cent of older Australians have identified face-to-face learning as their preferred option for building digital skills and confidence.

Face to face

A lack of consistency of referral to appropriate assessment is an issue within the system, especially at the entry point. We believe one of the reasons this continues to be the case is that those entering the system are assessed for eligibility to face-to-face services.

We believe that face-to-face service should be available to all older people to help them access appropriate assessment, services and care.

All older people have the right to be seen, heard and educated at a pace that works for them.

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Further, from a health perspective, face-to-face appointments provide an opportunity to detect possible risk factors and issues that the older person may not be willing to share or may not be apparent online or by phone.

Recommendation 4

Establish a peer educator program that engages retirees to help older Australians navigate

the aged care system.

Recommendation 5

Engage specialist support workers to visit people in their homes and communities in rural and remote areas and help them navigate the aged care system.

Recommendation 6

Position the allied health workforce as key sources of information about navigating the aged care system to facilitate access.

Recommendation 7

Develop a comprehensive consumer-facing campaign to educate the broader community about new changes to the aged system, including education about the value allied health providers can make to an older person

Recommendation 8

Implement face-to-face learning initiatives to improve digital literacy and confidence among older Australians.

Recommendation 9

Ensure face-to-face assessments and services are available to all older people to help them access appropriate assessment, services and care.

Investment stream

Comprehensive assessment by a health professional to determine the need for home modifications, assistive technologies and restorative and respite care will ensure the needs of the older person are met – and engender a more proactive and preventative approach.

Research has shown that significant savings could be made in health and aged care by increasing investment in assistive technology, as outlined in the National Disability Insurance Scheme Assistive Technology Strategy. This is because providing timely access to affordable assistive technology can:

• reduce the need for GP visits

• reduce demand for home care services

• reduce hospital admissions.

• delay entry to residential care (National Disability Insurance Agency, 2015).

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Admission into respite to reduce the burden of care can often be a signal of other undetected health issues. The system needs to be reoriented to enable a comprehensive assessment and intervention by a health professional at this stage.

Respite care is an important area of care that is not adequately resourced or aligned with other areas of health care. Existing respite care in Residential Aged Care Facilities (RACFs) is not working as it is social respite only. Restorative therapies must be included to build capacity within each individual to improve their level of function and reduce their burden of care.

This could be supported by a debit card that the consumer and their representative can use to purchase allied health restorative therapies.

A lack of knowledge about the value of physiotherapy may be a barrier to a block funding/debit card system being effective. Consumer awareness activities would be required to support this.

Home modification and assistive technologies could be done in a similar fashion to the NDIS where a physiotherapist, occupational therapist or speech pathologist assesses the older person and makes a recommendation to an external body who approves the plan and releases the funds for the equipment and modifications.

The entire aged care workforce must be upskilled to improve care management and increase recognition of the value of regular and planned respite for ageing people and their primary carers.

Crisis interventions

When an older person experiences a crisis or sudden change in circumstances, it is important that they are looked at holistically through a biopsychosocial lens.

The most important intervention at this critical juncture is a comprehensive assessment conducted by the most relevant health professional from a multidisciplinary team.

The APA believes comprehensive assessment and care delivered by a multidisciplinary team

is the model to optimise wellness, health and quality of life.

There is strong evidence of the benefits of strong and comprehensive care management by

multidisciplinary teams for older people.

Research has shown that frailty and reduced mobility can be successfully treated using an

interdisciplinary multifaceted treatment program (Cameron, Fairhall, & Langron, 2013).

Other studies demonstrated that multifactorial, interdisciplinary intervention reduces mobility-

related disability in frail older people and that for frail older people in the community, a 12-

month multifactorial intervention provided better value for money than usual care. This was

particularly for the very frail, in whom it has a high probability of being cost saving, as well as

effective (Fairhall, Sherrington, & Kurrle, 2012).

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Recommendation 10

Enable early comprehensive assessment and care delivered by a multidisciplinary team to

optimise wellness, health and quality of life.

Funding for new interventions

We believe that an aged care model focused on reablement, preventive and restorative care

reflects best practice care.

There is great opportunity to improve the quality of care provided to older people by

embedding restorative and reablement care as a key support service. The individual’s social,

economic, environmental and physical attributes must be considered a key pillar of

physiotherapy care.

Currently, older Australians moving from home packages into residential aged care lose

access to allied health restorative and reablement therapies.

Reablement care focuses on strategies that maintain or improve functional ability and

independence, through maximising an individual’s intrinsic capacity and the use of

environmental modifiers. Currently lacking in the Australian policy context is a true

reablement focus supporting best practice and quality outcomes for older Australians.

Research shows that prioritising physical rehabilitation and activity programs to maintain mobility, strength, flexibility and balance works (Bradshaw, Playford, & Riazi, 2012). As a proven modality, physical activity programs should be implemented as both a preventive and therapeutic intervention for the older resident within RACFs (De Souto, L, B., & Rolland, 2015). In meeting reablement goals, targeted physiotherapist-led programs support a range of quality outcomes including maintaining mobility, independence in activities of daily living, prevention of frailty and falls and broader social participation gains (Bradshaw, Playford, & Riazi, 2012) (Crocker, Young, Forster, Brown, Ozer, & Greenwood, 2013).

Progressive resistance strength training (PRT) is an appropriate intervention for many older people to improve performance. The review of randomised-controlled trials by Lui and Latham (2009) to assess the effects of PRT on older people (121 trials with 6,700 participants) was positive. The study demonstrated that PRT two to three times a week can improve physical function in older adults. Positive effects included reducing physical disability, some functional limitations (i.e. balance, gait speed, timed wa lk, timed ‘up-and-go’, chair rise; and climbing stairs) and muscle weakness as well as a reduction in pain in people with osteoarthritis

The findings of a Malaysian study by Justine M et al. (2012), found that 12-week multicomponent exercise training improves physical functioning among institutionalised elderly. Their study showed multicomponent exercise intervention improved cardiorespiratory endurance, muscle strength and balance performance (Justine, Hamid, Mohan, & Jagannathan, 2012).

A South Australian study by Crotty et al 2008 identified strategies to improve hip fracture outcomes in those from residential care. In outlining a forgotten cohort, the study states that those from residential care had short hospital stays, less rehabilitation and access to

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physiotherapy. Although 61% of those from residential care were classified as independently mobile pre-fracture, by 4 months this had declined to 32% of survivors.

Key factors in improving outcomes include: early identification of those walking independently pre-fracture with assessment by rehabilitation teams. The inclusion of liaison with community therapists in the clinical pathway, and in selected cases, use of ‘rehabilitation at home’ services to provide physiotherapy services should be considered.

The Sunbeam Program has provided results that are more definitive in effectiveness of

exercise interventions to guide future policy. The results of the trial demonstrated a 55 per

cent reduction in falls by people who participated in the exercise program and a projected

cost saving of $120 million per year for the Australian health economy (Hewitt, 2018).

Resources to support high quality and safe care options provided by physiotherapists must

be adopted.

Recommendation 11

Fund a 12-week, restorative and reablement program of physiotherapy at admission into a

residential aged care facility and after a significant trigger event such as a hip fracture.

Care stream

We acknowledge this model is a step forward and it is pleasing to see physiotherapy recognised via the care stream.

As has been discussed, the APA believes it is essential that the older person can easily access care that is appropriate, timely, safe and of high quality, and that this care is available across the older person’s lifespan, irrespective of setting location.

The role of prevention and early intervention is critical and should not be segregated by location. The appropriate care can prevent, improve, delay or enable better management and maintenance of functional decline across the ageing lifespan.

Physiotherapy-led exercise is protective in slowing the progression of neurodegenerative diseases, including Alzheimer’s disease and Parkinson’s disease. A study by Paillard et al. (2015) demonstrated that physiotherapy combining aerobic exercise with strength and balance training improves cognitive and motor functions (Paillard, Rolland, & de Souto Barreto, 2015).

It is essential to identify early signs of decline in independence and function and to initiate a reablement and restorative approach to optimise opportunities for return of function and independence. Multiple studies highlight the benefit of a reablement or restorative approach in the community through time-limited allied health or trained care staff intervention, aimed at improving functional ability (Lewin, K., Knuiman, Alan, Boldy, & Hendrie, 2013).

Unfortunately, many older people only access a comprehensive allied health assessment, and physiotherapy, when they have more significant functional decline. At this stage intervention is focused on ensuring the person remain safe while awaiting a home care package. It is imperative they have the opportunity to commence a restorative allied health program. An appropriately assessed and delivered allied health program could start

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immediately while the person is waiting for their home care package, to prevent further costly health decline.

At present there is a lack of transparency at the interface between community and residential care. When an older person has a home care package, they can see the cost of allied health but once they move into a RACF this transparency ceases. The APA believes there should be budget transparency across community and RACF settings, so each person clearly understands their care costs for reablement and restorative therapies.

The APA supports the Commonwealth’s proposed new funding model, Australian National Aged Care Classification (AN-ACC). However, the APA does not support the concept that allied health restorative and reablement care is part of the fixed cost component. We believe restorative and reablement therapy need a separate layer of funding to ensure each older person has some control over the care they receive. This would result in AN-ACC expanding to three layers of funding for fixed care, individual care and restorative/reablement care.

Block funding/debit card

The AN-ACC functions essentially as block funding with a layer of individual, needs- based funding. The APA strongly believes that older people and their representatives must have choice and control about where and what care they receive. Therefore, we welcome the concept of a proposed debit card with a fixed annual budget.

We anticipate a debit card could be used to support and improve access to reablement and restorative therapy within the three existing domains of aged care – Commonwealth Home Support Program (CHSP), Home Care and Residential Care. Aligning with the underpinning principles of the new aged care system, the older person, in collaboration with their family, general practitioner and/or care manager, should determine annual expenditure.

The ethos of this card should reflect the fundamental desire to offer people real choice through designing a purchasing mechanism that reflects individual needs and provider choice. This payment model would also enhance continuity of care by enabling the older person to maintain the same therapist in their home and when they move into a RACF.

Specialist and in reach services

Effective shared electronic health records will greatly improve communication between health and aged care services, ensuring consistency and safe treatment.

Physiotherapists report the disconnect between settings that in many instances leave patients exposed to substandard care, due to lack of preparation and/or resourcing, creates mental stress and discomfort and can result in regression.

Shared electronic health records backed by training in the use of these systems are urgently required.

There is an urgent need for physiotherapists and other health professionals to be adequately trained and supported in the use of such systems to enable them to best care for older people in the transition between health and aged care.

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Telehealth

Telehealth is a proven, safe and cost-effective strategy for increasing access to physiotherapy services for all Australians and there is a broad, and rapidly increasing, body of evidence that demonstrates this.

Reports suggest that sufficiently scaled home telehealth implementation is an appropriate and cost-effective way of managing chronic care clients in both urban and rural settings.

A systematic review that assessed the economic value of video communication found that:

• 91% reported telehealth outcomes were at least equivalent or better

• 61% found telehealth to be less costly than the non-telehealth alternative (Wade, Karnon, & Elshaug, 2010).

Difficulty in accessing physiotherapy services can be a result of multiple barriers, not only geographic. Video-consultations can lower the barriers for patients to receive advice and support.

This includes people living in rural locations, those who are homebound and older people with limited capacity to travel to a clinic (Foley & Lardner, 2014).

Given recent technology advancements that have simplified the user experience and reliability, telehealth is now an obvious solution to current access issues and can be effectively used to deliver many services, to review patient progress, ensure effective services are delivered and provide motivation for effective management programs. Telemedicine is also a proven cost-effective strategy for chronic pain management, providing a solution the current opioid dependence epidemic and extended wait lists for specialist pain services

Allied health professionals need to be enabled to work more easily across health and aged care settings. However, a barrier to this is the declining workforce. Telehealth and other technology that allow allied health practitioners to provide consultations in RACFs and in the community will bolster the workforce and the quality of service by reducing travel and costs.

Recommendation 12

Fund provision of physiotherapy services via telehealth to ensure all older Australians have access to safe and high quality care.

Designing for diversity

Co-design

APA supports applying a human-rights based approach to the design, delivery and

monitoring of services for older people. We believe in meeting the needs of people with

diverse backgrounds by co-designing tailored and appropriate services.

Working with diverse groups to understand their needs is key to an accessible aged care system. Rural and remote, Aboriginal and Torres Strait Island, CALD and LGBTI communities must be engaged to identify the current gaps, barriers, opportunities and

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tailored requirements to enable equitable access to information, assistance, services and safe care.

We support collaboration with older people from all cultures and backgrounds to ensure they have input into how best to enter the system and access support and services. Older people should also be actively engaged in evaluating the effectiveness of the information and system itself.

Analysis by the British Medical Journal (2015) has shown that codesign represents a radical reconceptualisation of the role of patients and a structured process for involving them throughout all stages of quality improvement. Our focus needs to shift away from collecting more data on patient experience, towards embedding codesign as a way of doing things.

Special effort must be made to understand the communication needs of those living in rural and remote areas, including the 65% per cent of Aboriginal and Torres Strait Islander peoples who live outside major cities (Australian Bureau of Statistics, 2016).

The Aged Care Diversity Framework, underpinned by the human rights based approach, should guide this work.

We believe designing for diversity must be:

• co-designed with diverse groups and communities to understand specific needs including transport issues and cultural beliefs, to ensure care is structured appropriately for that cohort

• consumer-centric, tailored and individualised

• delivered by trusted providers as specified by the community

• focused on building community-based capability

• aligned to systems such as the Patient Assisted Transport Scheme to break down silos and ensure smooth transitions

• enable consumer experience reporting

• supported by consumer education and resources to understand what quality care is and how to report any concerns

Recommendation 13

Collaborate with older people from all cultures and background to co-design and evaluate the effectiveness of the aged care

Quality regulation

The APA recognises the ongoing need for consumer protection, particularly in light of the Royal Commission. However, we oppose additional regulatory oversight of the profession.

Physiotherapy is an AHPRA profession and providers are required to meet minimum regulations set by AHPRA in order to maintain annual registration.

The Physiotherapy Board of Australia works in partnership with AHPRA to implement the National Registration and Accreditation Scheme, under the Health Practitioner Regulation National Law.

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In addition to AHPRA, the APA, as the peak body for physiotherapists, ‘regulates’ the sector with an APA Code of Conduct. The Code sets out the ethical foundation and professional obligations for APA members. It acknowledges the moral responsibility of physiotherapists to clients (including older people), families, colleagues, the communities they work with and the healthcare system they work within.

The four principles of the Code of Conduct are:

• Respect the rights and autonomy of the individual

• Cause no harm

• Advance the common good; and

• Act fairly The Code stipulates physiotherapists work to prevent, manage and mitigate harm.

The principles in the Code of Conduct support a value-base framework that guides and strengthens physiotherapist’s capability to make ethical decisions and provide safe, quality care.

National Professional Standards Panel

The APA also convenes a long-standing National Professional Standards Panel (NPSP). The purpose of the NPSP is to educate, encourage and assist APA Members to uphold standards of professional conduct, meet professional and ethical obligations of the APA Code of Conduct and achieve a high quality standard of practice.

In the event that a complaint is made against a member physiotherapist, the NPSP acts as a peer response mechanism. The outcomes may vary from escalation of the case to the AHPRA, or other disciplinary action. The NPSP also has a role in remediation should this be appropriate for the involved physiotherapist.

Skilled workers

We are aware from the disability sector that underskilling at the assessment/screening phase has had negative impact on people living with disability.

A lack of knowledge about health care, the value of different disciplines and the needs of participants has resulted in inconsistent treatment of the same conditions, inappropriate allocation of funds, inequity of funds allocation and treatment time, among other issues. It is clear that significant investment in upskilling planners would be required to rectify this problem.

We have concerns that this situation may be replicated in the aged care sector if those conducting screening and assessments and Care Finders are not appropriately skilled. The preferential use of allied health practitioners in these roles must be considered to ensure older Australians are receiving expert advice at each stage of their journey through the aged care system.

It is currently an issue that older people struggle to find independent advice. The success of the care stream will be contingent on appointing the right person to act as the care finder, independent of the organisation providing the care, to ensure there is no bias.

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However, the APA disagrees that the system should wait until the older person’s needs go beyond what can be managed, before an allied health professional is engaged. We support a preventive approach to ensure optimal health and wellbeing, delay the onset of serious conditions and the need for high care packages, and delay entry to aged care facilities. Allied health services should be available to all across the whole continuum.

Family support should not be considered as part of the individual’s support needs assessment. Families – who are unskilled workers – should be relieved of the burden of basic care and enabled to provide the social and community links, improving the quality of life of the older person.

Recommendation 14

Avoid additional regulation of already highly regulated registered allied health professions including physiotherapy.

Recommendation 15

Preferential appointment of allied health workforce to conduct early screenings and in the role of Care Finders to ensure older Australians receive correct and expert advice at each stage of their aged care journey.

Conclusion

The APA is committed to improving the design of the aged care program and quality of care

provided to older Australians. We would welcome the opportunity to provide evidence to the

Commission and to work with the Commission and other stakeholders on the reforms that

emerge.

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Australian Physiotherapy Association

The APA vision is that all Australians will have access to quality physiotherapy, when and

where required, to optimise health and wellbeing, and that the community recognises the

benefit of choosing physiotherapy.

The APA is the peak body representing the interests of Australian physiotherapists and their

patients. It is a national organisation with state and territory branches and specialty

subgroups. The APA represents more than 28,000 members who conduct more than 23

million consultations each year.

The APA corporate structure is one of a company limited by guarantee. The APA is governed

by a Board of Directors elected by representatives of all stakeholder groups within the

Association.

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